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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Qiality Control Inspection, Inc. Address1295 N a <br /> Emerld Modes>�o U5R5� <br /> owner R&A Hendershott Address 28100 South Hiway <br /> a 33 Tracy 9537B <br /> J Firm Partners, Addresses and Telephone Numbers David Romano, P.E. (209) �21 <br /> a Business Telephone No. _(209) 527-4940 Emergency Telephone No. <br /> a <br /> Contractor Licence No.NA/ Engineering-Testing-Inspect ion Firm <br /> C I B Jess Wry, P.E. __ - Title U R Em lovee Date 3,110 192 <br /> Applicants Name (Print)Q.C. y � P- <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30. 19 Disposal Sites <br /> Description(Make/Yr., Color) — - <br /> Serial No. CAL. License No. _- _ CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. -- - <br /> Equipment Parking Address -- -- - <br /> 2. ❑ PUMPER YARD <br /> For July 1,__ -- June 30, 19 <br /> No. of Vehicles Stored - -No IN <br /> Chemical Toilets Stored _ -- - <br /> 3. L3 PERCOLATION TEST <br /> R.S. or R.C.E. Name Quality Vontrol inspection _ R.S. or R.C.E. No. MS-92-14 <br /> Test Location See Map Test Date/Time Will Call - - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - - - <br /> Type Construction _ - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner or licensed agent's signature certifies the following:"I certify Mat in the pnrformance of the work for Which this permit is issued,I shall not employ ary perso. <br /> in such manner as to become subject orkmati-cura PdSa'I(w iay.' '.'4',jifori4l. <br /> Contractor's hiring or subcontracting signature certifies the iollowtug. t oertiry ibis;n the perfonnance of the work for which this permit is issued,I-hall <br /> employ persons subject to workman's compensatiun taws of Ca(itolnia.' <br /> I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stn laws, and �Ulesnd r ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Jess Wry, P.E. <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS (CJ/ <br /> PRORATION 11 <br /> PLUS �[iC 1�QS7S ✓Lt r.- �S�cl - <br /> PENALTY <br /> OTHER <br /> OTHER 3 S PuS <br /> ck� <br /> eceive DaR ` Recl-' t No Per Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />